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� <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> �. INSTALLATION CHECKLIST I <br /> � <br /> Installalior Company�ame 2nd Conlacl Inlo: � '� l��uV'Yl��. �� v � �.+1. I �= � <br /> Dale BacY,waler Prevention device(BWD)was instal!ed: Date this form tivas completed: ; <br /> Installation Property O�vner Name and Conlacl1!n`o: W� �1 � L�'1 � �S �10� -1�14� � <br /> PropertyNddress: � / �� � U`�1 �7 �- / � ��_��-"�T , <br /> � <br /> Pre•Installation Inspection Checklist: I <br /> All items must be chetked'Yes'in orde�for a B1ND to be considered for insfallation j <br /> Is there a basement or level of the house that is at or rear assumed sev�er main elevalion7 [j�j Yes ❑No t <br /> Are there fixlures in Ihe house located below Ihe upslream sewer manhole rim elevat�on?�Yes ❑No ! <br /> is the side se�ver currenUy UNPROTECTED Irom ser�er backups(does not have a BWD installed)? Q Yes ❑No + <br /> Site Inspection Checklist: f <br /> All i(ems must be checked'Yes'befae inspection is considered complete _. I <br /> �1'as side sewer TV inspecled from building lo se�ver main7 ��Yes ❑No Condition:l�✓�— �'` e�`4 c'/�. ' <br /> Dces side sewer have af least 1`/a slope Irom lhe building to se�ver main? �Yes ❑ No Deseribe: <br /> Have all build�rg see�er drain conneclions lo the side sewer been identified and localed7 �Yes ❑ No <br /> Have all property slorm drainage connections to lhe side se�ver been idenli6ed and located? [�Yes ❑�o <br /> Has property been evalualed(or drainage defciencies with findings communicated to property owner� ❑Yes ❑No <br /> Installation Details: ' <br /> What lype znd brand o(BWD was installed al this s�te(Clean Check BIhN,Grinder pum , r,ic): .�u e-�� � <br /> Where�vas Ihe device inslailed (general clescription, attach map}7 �n�lc � i�t �/i�� - � r� � <br /> Was there any other seerer or slorm drainage work compleled in conjunction ti�ith the BWD work7 Is so please describe _ <br /> lJl� <br /> installalion Checklist: <br /> Are ail dovmspouts and site drainage disconnected from upstream of thr, BWD7 [�Yes ❑No Comments: ct�Q I <br /> Does DWD posiliomng meels minimum slope requirement o(yi%? �-'les ❑ No Comments:�;M� ' <br /> � j <br /> Can BWD be pulled oul(or inspection and maintenance after loosening ihumb scre�v? [�Yes ❑ No <br /> Is BUVD locked into the proper position and thumb screw tightened7 �es ❑No ( <br /> Circle Ihe BWD cover:irrigation cover(landscape area)!traffic load bearing cover(drive surfaee)I access hatch(building) <br /> Was property owner shovrn Ihe location oi Ihe inslalled BWD7 [�Yes ❑ No Commenls: � <br /> Pmperty Owner's Signalu .. , � / ���� Date: � <br /> Installer's Signature: � Date: ��"�'�sf I <br /> Re��ision: 2 1 friday,Seolember 12, 20]4 ! <br /> i <br /> I <br /> i <br />